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Ptsd/ Depression Exam


mtbrad82

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I had a c&p last week and was just wanting some input if possible

LOCAL TITLE: C&P EXAMINATION STANDARD TITLE: C & P EXAMINATION NOTE DATE OF NOTE: STATUS: COMPLETED Initial Post Traumatic Stress Disorder (PTSD) Disability Benefits Questionnaire * Internal VA or DoD Use Only * Name of patient/Veteran: SECTION I: 1. Diagnostic Summary ---------------- Does the Veteran have a diagnosis of PTSD that conforms to DSM-5 criteria based on today's evaluation? [ ] Yes [X] No If no diagnosis of PTSD, check all that apply: [X] Veteran's symptoms do not meet the diagnostic criteria for PTSD under DSM-5 criteria [X] Veteran has another Mental Disorder diagnosis. Continue to complete this Questionnaire and/or the Eating Disorder Questionnaire:

Current Diagnoses ------------------- a. Mental Disorder

Diagnosis #1: Major Depressive Disorder, Recurrent,Moderate Mental Disorder Diagnosis

#2: Other Specified Trauma and Stressor-related Disorder

Comments, if any: Veteran does not currently meet the full criteria for PTSD. Veteran meets part of the criteria for PTSD largely due to his dysphoria symptoms (i.e. emotional numbing, and interpersonal detachment), sleep issues, irritability, and issues with concentration. Additionally, Veteran's stressor has not been conceded on the 2507.

b. Medical diagnoses relevant to the understanding or management of the Mental Health Disorder (to include TBI): Please see Medical Records

3. Differentiation of symptoms -----------------------------

a. Does the Veteran have more than one mental disorder diagnosed? [X] Yes [ ] No b. Is it possible to differentiate what symptom(s) is/are attributable to each diagnosis? [ ] Yes [X] No [ ] Not applicable (N/A) If no, provide reason that it is not possible to differentiate what portion of each symptom is attributable to each diagnosis and discuss whether there is any clinical association between these diagnoses: Veteran reports experiencing symptoms of both anxiety due to the trauma and depression, which are similar in characteristics such as irritability, issues with sleep, and difficulty concentrating. Symptoms of both disorders can be exacerbated by one another also. c. Does the Veteran have a diagnosed traumatic brain injury (TBI)? [ ] Yes [X] No [ ] Not shown in records reviewed

4. Occupational and social impairment ------------------------------------ a. Which of the following best summarizes the Veteran's level of occupational and social impairment with regards to all mental diagnoses? (Check only one) [X] Occupational and social impairment with reduced reliability and productivity b. For the indicated level of occupational and social impairment, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by each mental disorder? [ ] Yes [X] No [ ] No other mental disorder has been diagnosed If no, provide reason that it is not possible to differentiate what portion of the indicated level of occupational and social impairment is attributable to each diagnosis: The assessment of functioning indicates the veteran's overall level of functioning, which is affected by his symptoms of each disorder. The level of impairment the veteran is experiencing from his symptoms of anxiety due to trauma cannot be separated from the level of impairment the veteran is experiencing from his symptoms of depression. c. If a diagnosis of TBI exists, is it possible to differentiate what portion of the occupational and social impairment indicated above is caused by the TBI? [ ] Yes [ ] No [X] No diagnosis of TBISECTION II: ---------- Clinical Findings: 1. Evidence review ----------------- In order to provide an accurate medical opinion, the Veteran's claims folder must be reviewed.

a. Medical record review: ------------------------ Was the Veteran's VA e-folder (VBMS or Virtual VA) reviewed? [X] Yes [ ] No Was the Veteran's VA claims file (hard copy paper C-file) reviewed? [ ] Yes [X] No If yes, list any records that were reviewed but were not included in the Veteran's VA claims file: If no, check all records reviewed:

[X] Military service treatment records [ ] Military service personnel records [ ] Military enlistment examination [X] Military separation examination [X] Military post-deployment questionnaire [X] Department of Defense Form 214 Separation Documents

[ ] Veterans Health Administration medical records (VA treatment

records)

[ ] Civilian medical records

[ ] Interviews with collateral witnesses (family and others who have known the Veteran before and after military service)

[ ] No records were reviewed

[X] Other: Records in CPRS and VistaWeb reviewed b. Was pertinent information from collateral sources reviewed? [ ] Yes [X] No

2. History ---------

a. Relevant Social/Marital/Family history (pre-military, military, not listing

c. Relevant Mental Health history, to include prescribed medications and family mental health (pre-military, military, and post-military): Veteran denied any history of mental health treatment prior to enlisting into the service. Report of Medical History, dated,

06-05-2013, noted that Veteran experienced anxiety, depression, insomnia, panic attacks, and weight loss while in service. Veteran stated that he did receive mental health treatment while in service, starting in 2012 until his discharge in 2013. Veteran stated that he was hospitalized once in June 2013, at xxxxxxx in xxxxx, because of suicidal ideation. STRs indicate the following mental health treatment:

06-03-2013: Treatment with xxxxxxxx and diagnosed with Depression

06-12-2013: Treatment at xxxxxxxxx Center ER and diagnosed with Moderate Depression; Admitted into the facilty and discharged on 06-14-2013; diagnosed with Major Depressive Disorder, Recurrent, Moderate, with GAF=55

09-04-2013; Problem list noting Depression, Insomnia, Psychiatric Diagnosis on Axis I, and Adjustment Disorder with Depressed Mood Post-Deployment Assessments:

05-11-2010: Reported that health was "somewhat better now than before deployment;" denied any exposure to blasts/explosions, vehicle accidents, falls, or other events; denied expsoure to dead bodies; did not feel in great danger; denied any PTSD symptoms; reported that he did discharge his weapon and had direct combat

08-30-2010: No reported Mental Health Issues; no reported exposure to traumatic events and no reported PTSD symptoms

Veteran's records indicate that he has received the following mental health treatment since his discharge from the service:

01-31-2014: Treatment with Dr.xxxxxxxx and diagnosed with Major Depressive Disorder, Recurrent, mild to moderate

04-10-2014: Treatment with Dr. Xxxxxxxx and diagnosed with Depressive Disorder NOS

04-23-2014: Treatment with xxxxxxx, SW and diagnosed with Depression, Anxiety, and Explosive Anger; last seen 07-02-2014

04-28-2014: Attendance to one Anger Management Class, led by xxxxxxxxx, HC 07-25-2014: Treatment with Dr. Xxxxxxx and diagnosed with Psychosis NOS and Rule Out of PTSD

Veteran is currently prescribed the following psychiatric medication: Mirtazapine, Risperidone, and Escitalopram. Veteran stated that the medication has been effective, but "I still have times that I can't control so that's why I try to distance myself from people." Currently, Veteran is currently experiencing symptoms of depression, including sadness, reporting "I'm never happy." Veteran also indicated that he social withdraws/isolates, loss of interest in activties, lack of motivation, increased fatigue, forgetfulness/easily distracted, irritated easily, feelings of hopelessness, feelings of helpless, significant weight loss of 50 lbs in a 2 month timeframe after the death of his maternal grandmother, and issues with sleep.

Veteran stated that he was diagnosed with sleep apnea and received sleep apnea machine while in service. Veteran stated that he sleeps about 3-4 hours a night, and reported that he experiences issues with maintaining sleep. Veteran stated that his sleep is disrupted because of his physical pain, specifically pain in his knees, and because of thinking of things. Veteran reported that he experiences nightmares about "my days in Iraq." Veteran stated that he experiences the nightmares about 3-4 times a month. Veteran stated that he hears voices at night, through his dreams. Veteran stated that the voices are those of his deceased grandmother and other soldiers that he served with. Veteran stated that he hears the voices about 1-2 times a month. Veteran stated that his wife informed him that he will "atlk in my sleep about the deployments." Veteran stated that he startles easily and stated that his recollections of Iraq will be triggered by "sudden, loud sounds." Veteran stated that he will respond with anxiety, increased heart rate, and nervousness. Veteran stated that this will occur about 1-2 times a "if month. Veteran stated that he currently resides in a gated community and stated that he decided to live in this area for safety reasons. Veteran stated that he is hypervigilant, double-checking doors and locks and closets. Veteran stated that he will check these things I'm gone for an extended period of time. I have to make suI'm still safe."

Veteran stated that he talks to other military friends about his service experiences. Veteran stated that he "hated the military for a while," around the time of his grandmother's death. Veteran stated that he does not "feel like the military was there for me." Veteran also reported that he would not recommend to others to join the military. Veteran reported that he does not socialize with others, because of the quick angry outbursts. Veteran stated that when he becomes angry, he will be consumed with the anger. Veteran stated that he thinks that the anger occurs on its own, and though he attempts to control it, Veteran thinks his angry outburst and mood are unpredictable. Veteran stated that he becomes angry "whenever a situation don't go my way." Veteran stated that when he becomes angry at times, he will experience "hot and cold sweats" and tension in his body. Veteran recalled the angry that he felt when he was asked to contact his unit to extend his stay to attend his grandmother's funeral. Veteran stated that he "shouldn't had to do that." Veteran stated that he felt "alone" during this time and felt that others were not supportive or concerned about the mental health issues that the Veteran was coping with at the time, such as the significant weight loss and sadness. Veteran became tearful when discussing this during the exam. Veteran denied any current thoughts of suicide and/or homicide. Veteran stated that he has the phone numbers of the Crisis Hotline. Veteran stated that he started to experience mental health issues after his second deployment. Veteran reported that his anger has been "building" since 2011 and worsened after the death of his grandmother.

d. Relevant Legal and Behavioral history (pre-military, military, and post-military): Veteran reported that he is currently involved in a foreclosure. Veteran did not report any history of bankruptcy.

Veteran reported that following November 2013: Charged and arrested with Possession of Marijuana; released on bond; Veteran stated that he was not convicted with this charge January 2014: Charged and arrested for xxxxx and xxxxx against his wife; Charged were dropped in April 2014; Veteran stated that he was not convicted with this charge

e. Relevant Substance abuse history (pre-military, military, and post-military): Alcohol: 1st tried at age 18; Veteran stated that he "very rarely" consumes alcohol Cigarettes: 1st tried at age 19; denied any current use; Veteran stated that he only smoked cigarettes in Iraq, during this first deployment Marijuana: 1st tried at age 18; Veteran stated that he consumes marijuana daily; Veteran stated that it "helps me cope." Other Illicit Drugs: denied any history of use f. Other, if any: Death of not listed

3. Stressors ----------- Describe one or more specific stressor event(s) the Veteran considers traumatic (may be pre-military, military, or post-military): a. Stressor #1: Exposure in Iraq, specifically during second deployment Does this stressor meet Criterion A (i.e., is it adequate to support the diagnosis of PTSD)? [X] Yes [ ] No Is the stressor related to the Veteran's fear of hostile militar or terrorist activity? [X] Yes [ ] No Is the stressor related to personal assault, e.g. military sexual trauma? [ ] Yes [X] No

4. PTSD Diagnostic Criteria -------------------------- Please check criteria used for establishing the current PTSD diagnosis. Do NOT mark symptoms below that are clearly not attributable to the Criteria A stressor/PTSD. Instead, overlapping symptoms clearly attributable to other things should be noted under #7 - Other symptoms. The diagnostic criteria for PTSD, referred to as Criteria A-H, are from the Diagnostic and Statistical Manual of Mental Disorders, 5th edition (DSM-5).

riterion A: Exposure to actual or threatened a) death, b) serious injury, c) sexual violation, in one or more of the following ways:[X] Witnessing, in person, the traumatic event(s) as they occurred to others [X] Learning that the traumatic event(s) occurred to a close family member or close friend; cases of actual or threatened death must have been violent or accidental; or, experiencing repeated or extreme exposure to aversive details of the traumatic events(s) (e.g., first responders collecting human remains; police officers repeatedly exposed to details of child abuse); this does not apply to exposure through electronic media, television, movies, or pictures, unless this exposure is work related.

Criterion B: Presence of (one or more) of the following intrusion symptoms associated with the traumatic event(s), beginning after the traumatic event(s) occurred: No response provided.

Criterion C: Persistent avoidance of stimuli associated with the traumatic event(s), beginning after the traumatic events(s) occurred, as evidenced by one or both of the following: [X] Avoidance of or efforts to avoid distressing memories, thoughts, or feelings about or closely associated with the traumatic event(s).

Criterion D: Negative alterations in cognitions and mood associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of the following: [X] Persistent negative emotional state (e.g., fear, horror, anger, guilt, or shame).

[X] Markedly diminished interest or participation in significant activities.

[X] Feelings of detachment or estrangement from others.

[X] Persistent inability to experience positive emotions (e.g., inability to experience happiness, satisfaction, or loving feelings.)

Criterion E: Marked alterations in arousal and reactivity associated with the traumatic event(s), beginning or worsening after the traumatic event(s) occurred, as evidenced by two (or more) of of the following:

[X] Irritable behavior and angry outbursts (with little or no provocation) typically expressed as verbal or physical aggression toward people or objects.

[X] Hypervigilance.

[X] Exaggerated startle response. [X] Problems with concentration. [X] Sleep disturbance (e.g., difficulty falling or staying asleep or restless sleep).

Criterion F:

[X] Duration of the disturbance

(Criteria B, C, D, and E) is more than 1 month.

Criterion G:[X] The disturbance causes clinically significant distress or impairment in social, occupational, or other important areas of functioning.

Criterion H:

[X] The disturbance is not attributable to the physiological effects a substance (e.g., medication, alcohol) or another medical condition. Criterion I: Which stressor(s) contributed to the Veteran's PTSD diagnosis?:

[X] Stressor #1

5. Symptoms ---------- For VA rating purposes, check all symptoms that actively apply to the Veteran's diagnoses:

[X] Depressed mood

[X] Anxiety

[X] Suspiciousness

[X] Chronic sleep impairment

[X] Disturbances of motivation and mood

[X] Difficulty in establishing and maintaining effective work and social relationships

[X] Difficulty in adapting to stressful circumstances, including work or a worklike setting

[X] Inability to establish and maintain effective relationships

[X] Impaired impulse control, such as unprovoked irritability with periods of violence

6. Behavioral Observations ------------------------- Veteran is an African-American male, of average height and weight. Veteran's appearance/grooming was appropriate. Veteran demonstrated tense motor activity and was guarded initially during the exam. Rapport was slowly established. Veteran's speech was at a normal rate and volume was was low. His attention/concentration were intact. Veteran maintained appropriate eye contact during the exam. Affect was retricted and mood was anger and depressed. Veteran demonstrated average to above average intellectual functioning. Veteran's thought processes were linear and he did not display any perceptional issues/psychotic features. Veteran did not report any current thoughts of suicide or homicide.

7. Other symptoms ---------------- Does the Veteran have any other symptoms attributable to PTSD (and other mental disorders) that are not listed above? [ ] Yes [X] No

8. Competency ------------ Is the Veteran capable of managing his or her financial affairs? [X] Yes [ ] No 9. Remarks,(including any testing results) if any -------------------------------------- Veteran was aware of the reason for the evaluation. Veteran's stressor has not been conceded on the 2507. Veteran's completion of the Post-deployment Assessment did not indicate any exposure to blasts/explosions, exposure to dead bodies, losing consciousness, or experiencing PTSD symptoms. However, on the Memorandum Statement submitted by the Veteran, he noted that he "passed out for five to ten minutes from a mortar explosion that blew up equipment in our Combat camp." Additionally, it appears that Veteran's mental health symptoms are in large part due to the death of his maternal grandmother and the military's handling of the Veteran's attendance to her funeral and his grief reaction to the situation at the time. Stressors: Veteran stated that he was exposed to the "smell of death,"smell of burning bodies," "seeing dead bodies every few blocks," and incoming mortar fire. Veteran stated that he learned of fellow soldiers deaths during deployment. Veteran stated that he was directly exposed to combat. Veteran stated that while on his way to Qatar, he witnessed an Iraqi with an RPG. Veteran stated that the RPG "went by right in front of the truck" that the Veteran was in. Veteran stated that he witnessed vehicles being "blown up right in front of me."

NOTE: VA may request additional medical information, including additional examinations if necessary to complete VA's review of the Veteran's

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Due to the Occupational and Social Impairment Statement, it looks like you will be granted SC either at the 10 or 30% range. Good luck and keep us posted.

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